A 77-year-old Japanese female underwent laparoscopic ileocecal resection and lymph node dissection for cecal cancer by a previous doctor. Two years and 9 months after previous operation, contrast-enhanced computed tomography and magnetic resonance imaging with gadolinium ethoxybenzyl-L-diethylenetriamine pentaacetic acid revealed an intraperitoneal tumor at the right subphrenic fossa. 18F-fluorodeoxyglucose position emission tomography showed fluorodeoxyglucose accumulation in the tumor, and we suspected the tumor to be solitary distant peritoneal metastasis of the previous cecal cancer to the right diaphragm. We performed partial diaphragmectomy and direct closure, and pathological examination revealed moderately differentiated tubular adenocarcinoma resembling the previous cecal cancer, which seemed to be disseminated metastasis in the pathological features. Based on the intraoperative findings, we assumed the tumor to be solitary distant peritoneal metastasis caused by procedures during the previous laparoscopic operation. The present report suggests the importance of paying close attention to procedures during laparoscopic colorectal resection to prevent peritoneal seeding

Abe, Tetsuya

Ito, Seiji

Ito, Yuichi

Kawakami, Jiro

Kimura, Kenya

Kinoshita, Takashi

Komori, Koji

Misawa, Kazunari

Natsume, Seiji

Ouchi, Akira

Senda, Yoshiki

Shimizu, Yasuhiro

Uemura, Norihisa

Tokushima University Institutional Repository

INTRODUCTIONLaparoscopic colorectal resection, which is less invasive thanopen colorectal resection, has been increasingly used for colorec-tal cancer over the last two decades. Several large randomizedcontrolled trials have reported the superiority in terms of short -term outcomes, including earlier recovery of bowel function andshorter hospital stay to open colorectal resection (1-4). These trialshave also reported the equivalence in terms of long-term outcomes,including disease- free survival and overall survival to open colorec-tal resection (5-7) ; however, several recurrence patterns peculiarto laparoscopic colorectal resection, such as port site recurrenceand peritoneal seeding, are an issue in these days (8). Both port siterecurrence and peritoneal seeding are related to careless surgicalprocedures. We have to pay close attention to our procedures dur-ing laparoscopic surgery.We report a case of solitary distant peritoneal metastasis of cecalcancer after laparoscopic colectomy. This peritoneal metastasisseemed to be caused by surgical procedures. The present casereport highlights the importance of paying close attention to sur-gical procedure in laparoscopic surgery to prevent peritonealseeding.CASE PRESENTATIONA 77-year-old Japanese female underwent laparoscopic ileocecalresection and lymph node dissection for cecal cancer by a previousdoctor. Pathological examination revealed moderately differenti-ated tubular adenocarcinoma with positive lymph and blood vesselinvasion and serosal invasion. Lymph node metastases were seenin two of the seven dissected lymph nodes. Her pathologic stagewas T4aN1bM0 stage IIIB according to the TNM Classificationof Malignant Tumors 7th Edition. She had undergone adjuvantchemotherapy with oral capecitabine for 6 months. Two years and9 months after the previous operation, contrast -enhanced com-puted tomography (CECT) during a routine examination revealedan intraperitoneal tumor at the right subphrenic fossa ; therefore,she presented to our hospital for the treatment of the tumor.There were no remarkable findings during the physical exami-nation. Blood biochemistry showed elevation of carcinoembryonicantigen (6.2 ng/mL) and carbohydrate antigen 19-9 (104.4 U/mL)levels. CECT showed an intraperitoneal tumor with poor contrastenhancement at the right subphrenic tumor. We performed mag-netic resonance imaging with gadolinium ethoxybenzyl -L-dieth-ylenetriamine pentaacetic acid (EOB-MRI) in addition, and EOB-MRI also showed the right subphrenic tumor, which seemed tobe located on the right diaphragm and not invasive into the liver.(Figure 1). We also performed 18F-fluorodeoxyglucose positionemission tomography (FDG-PET) for a qualitative diagnosis, andFDG-PET showed fluorodeoxyglucose accumulation in the rightsubphrenic tumor (Figure 2). There was no evidence of furtherperitoneal metastasis or another distant metastasis on a previousseries of examinations ; therefore, we considered the tumor to besuspicious of solitary distant peritoneal metastasis of the previouscecal cancer. We expected the tumor to be curatively resectableand performed operation.During the operation, the tumor was located on the right dia-phragm close to the inferior vena cava and right hepatic vein(Figure 3). The tumor was not invasive into the liver as was preop-eratively diagnosed. There was no further peritoneal metastasisor another distant metastasis. We performed radical partial dia-phragmectomy and direct closure. The operation time was 1 h 22min, and blood loss was 10 g. A resected specimen contained awhite hard tumor, 2.01.5 cm in diameter. Pathological examina-tion revealed moderately differentiated tubular adenocarcinomaCASE REPORTSolitary distant peritoneal metastasis of cecal cancer afterlaparoscopic colectomy : a case reportAkira Ouchi, Koji Komori, Kenya Kimura, Takashi Kinoshita, Seiji Ito, Tetsuya Abe, Yoshiki Senda, Kazunari Misawa,Yuichi Ito, Norihisa Uemura, Seiji Natsume, Jiro Kawakami, and Yasuhiro ShimizuDepartment of Gastrointestinal Surgery, Aichi Cancer Center Hospital, Aichi, JapanAbstract : A 77-year-old Japanese female underwent laparoscopic ileocecal resection and lymph node dissectionfor cecal cancer by a previous doctor. Two years and 9 months after previous operation, contrast-enhancedcomputed tomography and magnetic resonance imaging with gadolinium ethoxybenzyl-L-diethylenetriaminepentaacetic acid revealed an intraperitoneal tumor at the right subphrenic fossa. 18F-fluorodeoxyglucoseposition emission tomography showed fluorodeoxyglucose accumulation in the tumor, and we suspected thetumor to be solitary distant peritoneal metastasis of the previous cecal cancer to the right diaphragm. We per-formed partial diaphragmectomy and direct closure, and pathological examination revealed moderately differ-entiated tubular adenocarcinoma resembling the previous cecal cancer, which seemed to be disseminatedmetastasis in the pathological features. Based on the intraoperative findings, we assumed the tumor to be solitarydistant peritoneal metastasis caused by procedures during the previous laparoscopic operation. The presentreport suggests the importance of paying close attention to procedures during laparoscopic colorectal resectionto prevent peritoneal seeding. J. Med. Invest. 64 : 288-290, August, 2017Keywords : peritoneal metastasis, colon cancer, laparoscopic surgeryReceived for publication January 10, 2017 ; accepted March 2, 2017.Address correspondence and reprint requests to Akira Ouchi, 1 -1Kanokoden, Chikusa, Nagoya, Aichi, 464 -8681, Japan and Fax : +81-52 -764-2963.The Journal of Medical Investigation Vol. 64 2017288resembling the previous cecal cancer, which seemed to be dissemi-nated metastasis in the pathological features (Figure 4). Based onthe intraoperative findings, we assumed the tumor to be solitarydistant peritoneal metastasis caused by procedures during the pre-vious laparoscopic operation. She showed satisfactory progress,and was discharged from the hospital on postoperative day 9. Wedid not perform adjuvant therapy after this operation because ofa lack of relevant evidence to support the use of adjuvant chemo-therapy for Stage IV colon cancer patients. She had remained wellwithout any signs of recurrence at the 1-year follow-up.DISCUSSIONSeveral large randomized controlled trials have reported the su-periority of laparoscopic colorectal resection in terms of short - termoutcomes and the noninferiority in terms of long-term outcomes(1-7) ; however, JCOG0404 study performed in Japan could notreveal the noninferiority of laparoscopic colorectal resection. Thisstudy reported the tendency of poor prognosis of laparoscopiccolorectal resection in advanced subgroups of cT4 or cN2 (9). Oneof the reasons of this poor prognosis is considered to be peritonealseeding by surgical procedures (8). It is unclear whether perito-neal seeding actually affect long-term outcomes in patients withcolorectal cancer. But we cannot entirely ignore this new type ofrecurrence peculiar to laparoscopic colorectal resection.Peritoneal metastasis generally occurs in patients with colorec-tal cancer naturally accompanied by serosal invasion ; however, can-cer cells from the primary tumor are sometimes seeded by surgicalprocedures even in either open or laparoscopic colorectal resection.More advanced techniques are required to perform oncologicallysafe procedures in laparoscopic colorectal resection than in opencolorectal resection. Inexperienced surgeons in laparoscopic col-orectal resection sometimes injure the tumor incidentally, result-ing in seeding of cancer cells. In the present case, the tumor was nothematogenous or lymphogenous, but disseminated metastasis.Figure 3. The white hard tumor was located at the right subphrenicfossa close to the inferior vena cava and right hepatic vein.Figure 1. The right subphrenic tumor seemed to be located on theright diaphragm and not invasive into the liver (arrowheads) by magneticresonance imaging with gadolinium ethoxybenzyl -L -diethylenetriaminepentaacetic acid.Figure 2. 18F- fluorodeoxyglucose position emission tomographyshowed fluorodeoxyglucose accumulation in the tumor.Figure 4. Pathological examination revealed moderately differenti-ated tubular adenocarcinoma resembling the pathology of the previouscecal cancer, which seemed to be disseminated metastasis in the patho-logical features (hematoxylin and eosin stain ;40).The Journal of Medical Investigation Vol. 64 August 2017 289Peritoneal disseminated metastasis of colon cancer generally oc-curs at the caudal end of the greater omentum including mesentery,bilateral paracolic gutter and rectovesical pouch (10). A recent studyreported that 14.1 % of pathologic T4 colon cancer developed me-tachronous peritoneal metastasis (11) ; therefore, in the presentcase, metachronous peritoneal metastasis is not unnatural in itself.As it is, solitary distant peritoneal metastasis of colon cancer cepha-lad beyond the greater omentum similar to the present case has notbeen reported previously. This pattern of metachronous peritonealmetastasis is unnatural in colon cancer. In laparoscopic colorectalresection for right-sided colon cancer, assistant surgeons some-times grasp the colon near the tumor using laparoscopic instru-ments, injure the tumor, touch the right diaphragm, and seedcancer cells incidentally. We do not have the information about thecondition of primary operation by a primary doctor, and we couldnot find conclusive evidence of incidental injury ; however, we as-sumed that it is possible to be the cause of solitary metachronousperitoneal metastasis in the present case. Few reports are availableon the mechanism of procedural seeding, and no studies supportour hypothesis ; therefore, we are planning the prospective studyof free cancer cells disseminated in laparoscopic colectomy forcolon cancer.CONCLUSIONSWe experienced a case of solitary distant peritoneal metastasisof cecal cancer after laparoscopic colectomy, which seemed to becaused by surgical procedures. The present case suggests the im-portance of paying close attention to procedures during laparo-scopic colorectal resection to prevent peritoneal seeding.CONFLICT OF INTERESTSThe authors declare that they have no conflict of interests.ACKNOWLEDGMENTWe thank Dr. Eichi Sasaki, Dr. Masashi Mikubo, and Dr. YasushiYatabe (Aichi Cancer Center Hospital, Department of Pathologyand Molecular Diagnostics) for pathological diagnosis. We thankCrimson Interactive Pvt. Ltd. for providing English proofreading ofour manuscript.REFERENCE LIST1. 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Akagi T, Inomata M, Katayama H, Mizusawa J, YamaguchiT, Masaki T, Fukunaga Y, Murata K, Okajima M, MunakataY, Sato T, Bandou H, Yasui M, Sekimoto M, Watanabe M,Sugihara K, Konishi F, Etoh T, Shimada Y, Kitano S : A ran-domized controlled trial to evaluate laparoscopic versus openwith Japanese D3 dissection for stage II, III colorectal cancer(CRC) : First efficacy results from Japan Clinical OncologyGroup Study JCOG0404. J Clin Oncol 33 (Suppl.), abst 3577,201510. Akasu T, Sugihara K : Solitary peritoneal metastasis from co-lon carcinoma. Surgery 124 : 938-940, 199811. Nagata H, Ishihara S, Hata K, Murono K, Kaneko M, YasudaK, Otani K, Nishikawa T, Tanaka T, Kiyomatsu T, Kawai K,Nozawa H, Watanabe T : Survival and Prognostic Factors forMetachronous Peritoneal Metastasis in Patients with ColonCancer. Ann Surg Oncol. 2016 Dec 19. [Epub ahead of print]290 A. Ouchi, et al. Peritoneal mets after lap-colectomy

Solitary distant peritoneal metastasis of cecal cancer after laparoscopic colectomy : a case report

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Solitary distant peritoneal metastasis of cecal cancer after laparoscopic colectomy : a case report

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